Provider Demographics
NPI:1427342286
Name:TAVAKOLIAN, AZITA (RPH)
Entity type:Individual
Prefix:MRS
First Name:AZITA
Middle Name:
Last Name:TAVAKOLIAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6134 BRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-2610
Mailing Address - Country:US
Mailing Address - Phone:703-644-0060
Mailing Address - Fax:703-644-0525
Practice Address - Street 1:6134 BRANDON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-2610
Practice Address - Country:US
Practice Address - Phone:703-644-0060
Practice Address - Fax:703-644-0525
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010998183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist